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In 2000 the UN published eight millennium development goals (MDGs) to be achieved by 2015.1 These eight goals were chosen to give an overview of progress on the larger development agenda and focus the minds of the international community. Two of the MDGs directly address women's reproductive health: to reduce maternal mortality by 75% and to halt and begin to reverse the spread of HIV/AIDS. While admirable, these goals ignore the prevalence of many treatable conditions causing disability and distress in women's lives.

The estimation of disease burden via Disability Adjusted Life Years (DALYs), as advocated by the World Health Organization, is an attempt to move away from mortality-based indicators.2 This approach allows a formal evaluation of the cost-effectiveness of interventions in order to assist with priority setting. The DALY is a single, comparable measure of a health outcome designed to quantify both premature mortality and disability. Having calculated DALYs lost through a disease or group of diseases, cost effectiveness is then measured in terms of cost of intervention ‘per DALY saved’. However, the DALY approach has been criticised because of the nature of the disability weights used and the quality of epidemiological estimates of incidence and duration. Disability weights are derived from assessments of the degree of disability resulting from a particular condition made by medical experts. This gives the DALY approach an emphasis on medical disability and is particularly problematic in gynaecological disease where the disability may be more social than medical. To accurately assess health status in its wider context, a measure of social or mental distress would be required as part of the measure of disability. However, it is still difficult to see how selective decisions about health care spending could be based on such an indicator as it does not capture women's distress from their own perspective. Moreover, the DALY calculations so far have excluded important gynaecological conditions such as fistula, genital prolapse and menorrhagia and have concentrated more on maternal conditions and HIV/AIDS.3

Accurate assessment of disease prevalence depends on accurate diagnosis, and this may be very difficult in poor settings. Only a few comprehensive community-based studies in low income countries have sought to quantify the burden of gynaecological disease in order to influence policy. These studies have consistently shown a high prevalence of previously unrecognised morbidity that places a heavy burden on women (Table 1).4–7 The wide range of gynaecological diseases found included menstrual disorders, genital prolapse, pelvic masses, reproductive tract infections, infertility, cervical dysplasia and related morbidity such as anaemia.

Table 1.  The prevalence (%) of gynaecological morbidity from cross-sectional community-based studies in low income countries.
StudyIndia4Egypt5India6Gambia7
Sample2 rural villages, all women aged ≥13 (n= 650)2 rural villages, ever married, non-pregnant (n= 509)Women with children aged 6–12 months, 1/4 urban–3/4 rural (n= 385)20 rural villages, all women aged 15–54 (n= 1348)
Menstrual disorders516234
Infertility71010
Reproductive tract infection68445647
Pelvic tenderness24191110
Cervical dysplasia2817
Genital prolapse56342
Gynaecologic masses616
Urinary Incontinence7

In a study in The Gambia, less than half of the women with reproductive health complaints had sought health care for their complaint.7 The most frequently reported reasons for not seeking health care were ‘I didn't think it would help’, ‘too expensive’, ‘problem not serious enough’ and ‘afraid/embarrassed’. Some disorders were thought to be not worth reporting because they were considered normal for the individual, because they were widespread or because there was a perception that nothing could be done. For example, women participating in semi-structured interviews on menstrual disorders were not aware of any treatments for irregularity or spotting.8 In this study, much information was obtained about the cultural context and perceptions of menstruation in a rural community. These findings demonstrate the importance of properly validating any questionnaire study of the prevalence of gynaecological problems, especially when being used to design reproductive health programmes.

One of the challenges is to adequately conceptualise gynaecological disease to the stage where meaningful data can be assembled from institutional and community survey sources. The comparison of studies is hampered by the wide variation in terminology and methods used. Hence, standard definitions of gynaecological disorders should be used that are well supported by published evidence and the data collection methods should not only be reliable, but easily used in a variety of resource-poor settings. But even if this is done a major problem remains: symptoms of reproductive illness reported to lay interviewers correlate poorly with biomedically diagnosed disease.9 If the priority is to estimate the prevalence of reproductive tract infections, there is no alternative to collecting biological samples for laboratory analysis. Thus, comprehensive community-based studies must not only include a self-report of symptoms and history taking, but also clinical and laboratory examinations. Such studies are both logistically demanding and costly. Inexpensive laboratory tests for many infections are, however, becoming available, and the further development of less intrusive methods of collecting samples (e.g. self-administered vaginal swabs and saliva-based tests) will make this option increasingly useful.

Questionnaire-based studies have limited value for diagnosis of gynaecological disease but are useful to capture perceived ill health. However, the collection of data about symptoms alone is not particularly useful. For surveys to fulfil their potential, supplementary information is needed concerning self-perceived severity of symptoms and their consequences for everyday life, on whether individuals resort to self-treatment or seek healthcare outside the home, on barriers to seeking professional help and about financial expenditures. Overall, attempts to measure health-related quality of life for gynaecologic conditions, with the exception of malignancies, have been rare.10 Such data are an invaluable component of biomedical studies for assessing the magnitude and implications of self-perceived reproductive health problems in a population and in setting priorities to address them.

The provision of services by itself will not overcome the ‘culture of silence’ surrounding many of the reproductive health problems. Reproductive health care providers need to stimulate the demand for services at the same time as they are meeting that demand. There is also a need for better understanding of behavioural factors, as well as gender and social aspects of health care. In primary health care clinics in Nairobi, Kenya, women's knowledge of sexually transmitted infections (STIs) and of health in general was poor, and a marked difference was observed in the speed of health seeking for STIs (5 days for men vs 14 days for women).11 Empowerment of women (and men) through education is a key factor in improving reproductive health.12 Not only are many reproductive health issues not subjects for public discussion, they are also seldom talked about even among peers. Reproductive choice and dignity will only be possible if prevalent notions harmful to reproductive health are questioned. Past neglect of reproductive health has often led to uninviting and inaccessible health services of poor quality. The combination of these factors represents an enormous challenge for under-resourced health services. The overriding challenge must be to increase community knowledge about gynaecological diseases, their symptoms, prevention and treatment.

So where do we start? The arguments from welfare economists for public funding of health care are persuasive when applied to reproductive health, and in many developing country settings it is difficult to envision serious reforms and improvement without increases in public sector spending. However, communities themselves should assume some responsibility for women's health in ways that prioritise women's own perceptions and primary needs. Such programmes should be actively developed and evaluated for cost, benefit and sustainability. But on a personal level, the social and financial empowerment of women is crucial. In many low income countries, women are currently often not in a position to attain and maintain their own health and wellbeing, and this has to be changed to be able to start addressing the large burden of gynaecological disease.

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